01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-17 | 8 | 2026-04-17 | 1 |
| Cycle 2 | 2025-05-09 | 7 | 2025-05-09 | 3 |
| Cycle 3 | 2024-06-25 | 11 | 2024-06-25 | 3 |
CMS CCN 3953352026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
William Penn Nursing And Rehab
163 Summit Drive · Lewistown, PA 17044 · Mifflin County
Certified beds121CMS provider file
Recent citation rows33current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
33 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-17 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2026-06-032026-04-17 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2026-06-032025-05-09 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-06-102025-05-09 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-06-102025-05-09 · HEALTHF0725Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2025-06-10 · complaint2025-05-09 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-06-102025-05-09 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-06-10 · complaint2025-05-09 · HEALTHF0791Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Correction field: Deficient, Provider has date of correction · 2025-06-102025-05-09 · HEALTHF0887Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Correction field: Deficient, Provider has date of correction · 2025-06-102025-05-09 · FIREK0362Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-102025-05-09 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-102025-05-09 · FIREK0929Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Correction field: Deficient, Provider has date of correction · 2025-06-102024-06-25 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2024-07-242024-06-25 · HEALTHF0637Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Correction field: Deficient, Provider has date of correction · 2024-07-242024-06-25 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-07-242024-06-25 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-07-242024-06-25 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-07-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- WESTERN PA OPCO HOLDINGS I LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/29/2024
- VALLEY WEST HEALTH LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/15/2024
- FRANCO, AHARONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/29/2024
- RAMI, ISAACIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/29/2024
- KARITY, SARAHIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 10/29/2024
- BEVERLY ENTERPRISES - PENNSYLVANIA, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- BEVERLY ENTERPRISES LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- BEVERLY HEALTH AND REHABILITIATION SERVICES, INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- DRUMM INTERMEDIARY SUB CO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- DRUMM MERGER COOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- DRUMM MERGER CO SUB LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- FILLMORE STRATEGIC INVESTORS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- GEARY PROPERTY HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- GPH LEWISTOWN LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- PEARL SENIOR CARE, LLC.Organization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- SURETY COMPLIANCEOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/29/2024
- VALLEY WEST HEALTH LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
- WASHINGTON STATE INVESTMENT BOARDOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/20/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.39per resident day
RN hours0.54per resident day
Weekend nurse hours3.13per resident day
Staff turnover35.6%CMS reported field
06 / LOCAL RECORDS
Open the Lewistown ledger →